Tracking Trends in Health system performance Too High a Price: Out-of-Pocket Health

The
COMMONWEALTH
FUND
Tracking Trends in
Health system performance
NOVEMBER 2014
Too High a Price: Out-of-Pocket Health
Care Costs in the United States
Findings from the Commonwealth Fund
Health Care Affordability Tracking Survey,
September–October 2014
The mission of The
Commonwealth Fund is to
promote a high performance
health care system. The Fund
carries out this mandate by
supporting independent research
on health care issues and making
grants to improve health care
practice and policy. Support for
this research was provided by The
Commonwealth Fund. The views
presented here are those of the
authors and not necessarily those
of The Commonwealth Fund or
its directors, officers, or staff.
Sara R. Collins, Petra W. Rasmussen, Michelle M. Doty,
and Sophie Beutel
Abstract Whether they have health insurance through an employer or buy it
on their own, Americans are paying more out-of-pocket for health care now than
they did in the past decade. A Commonwealth Fund survey fielded in the fall of
2014 asked consumers about these costs. More than one of five 19-to-64-yearold adults who were insured all year spent 5 percent or more of their income on
out-of-pocket costs, not including premiums, and 13 percent spent 10 percent or
more. Adults with low incomes had the highest rates of steep out-of-pocket costs.
About three of five privately insured adults with low incomes and half of those
with moderate incomes reported that their deductibles are difficult to afford. Two
of five adults with private insurance who had high deductibles relative to their
income said they had delayed needed care because of the deductible.
For more information about this
brief, please contact:
Sara R. Collins, Ph.D.
Vice President, Health Care
Coverage and Access
The Commonwealth Fund
src@cmwf.org
To learn more about new
publications when they become
available, visit the Fund’s website
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alerts.
Commonwealth Fund pub. 1784
Vol. 29
OVERVIEW
Over the past decade, Americans—whether they receive health insurance
from their employers or purchase it on their own—have seen a substantial
increase in the amount of money they pay when they go to a doctor or fill a
prescription.1 The share of workers covered by employer-based health plans
who faced a deductible climbed from 55 percent in 2006 to 80 percent in
2014, according to the Kaiser Family Foundation.2 In 2014, the average
deductible for a single policy in an employer plan was $1,217, more than
double the 2006 average of $584. More than two of five covered workers—
up from 10 percent in 2006—have deductibles of $1,000 or more.
Because median family income has grown very slowly over the past
decade, these trends mean that the amount U.S. families spend on health has
2
The Commonwealth Fund
grown as a share of income. For some families, this has led to underinsurance—their insurance coverage
does not provide adequate protection from the costs of health care. Prior research by The Commonwealth Fund has found that when people are underinsured they delay getting needed care at similar
rates as adults who lack coverage altogether.3 This is why the Affordable Care Act requires health
insurance policies sold in the individual and small-group markets to cover a comprehensive set of
health benefits, and why it provides greater financial protection for lower-income people who buy plans
through the marketplaces. But the law’s reach is limited. More than 150 million Americans get their
health insurance through an employer; 7.1 million bought plans through the marketplaces this year.
This issue brief assesses the financial protectiveness of health insurance coverage in the
United States by examining survey results from The Commonwealth Fund that track the affordability
of health insurance and health care among the nation’s adult population. Between September 10 and
October 5, 2014, the Commonwealth Fund Health Care Affordability Tracking Survey interviewed
a nationally representative sample of 2,751 adults ages 19 to 64 about the costs of their health insurance and health care.
THE COMMONWEALTH FUND’S MEASURE OF UNDERINSURANCE
In 2003, Cathy Schoen developed a measure of underinsurance for the Commonwealth
Fund Biennial Health Insurance Survey that takes into account an insured adult’s reported
out-of-pocket costs over the course of a year, not including premiums, and their health plan
deductible. These actual expenditures and the potential risk of expenditures, as represented
by the deductible, are then compared with household income. Specifically, someone who is
insured all year is underinsured if:
•
out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 10 percent
or more of household income; or
•
out-of-pocket costs, excluding premiums, are equal to 5 percent or more of household
income if income is under 200 percent of the federal poverty level ($22,980 for an individual and $47,100 for a family of four); or
•
the deductible is 5 percent or more of household income.
The Commonwealth Fund has reported changes in this measure every year it has fielded the
biennial survey. We will report an update of this measure in January 2015. With this smaller
and shorter tracking survey, we aim to periodically check in on what Americans are spending
out-of-pocket on their health care, their views of these costs, and how costs are affecting their
medical decisions.
SURVEY FINDINGS
Low-Income Adults Are the Most Likely Among Those Insured All Year to Spend
Large Shares of Their Income on Health Care
In the survey, people were asked how much they spent out-of-pocket for medical treatments and services that were not covered by their health insurance over the prior 12 months. They were asked to
think of all their expenditures, including copayments, when they went to the doctor or hospital, as
well as their costs for prescriptions and vision and dental care. We then calculated their estimates as a
share of their income. Among adults who had had health insurance for the full 12 months, more than
one of five (21%) spent 5 percent or more of their income on out-of-pocket costs and 13 percent
spent 10 percent or more (Exhibit 1).
Too High a Price: Out-of-Pocket Health Care Costs in the U.S.
3
Exhibit 1. Two of Five Insured Adults with Incomes Below the Federal Poverty Level
Spent 5 Percent or More of Their Income on Medical Out-of-Pocket Costs
Percent of adults ages 19–64 who were insured all year
75
Spent 5% or more of income
on out-of-pocket costs
50
41
31
25
0
Spent 10% or more of income
on out-of-pocket costs
31
21
18
13
Total
27
21
17
8
<100% 100%–
FPL
199%
FPL
200%–
399%
FPL
9
7
400%+
FPL
15
9
Fair/poor No health
health or problems
at least one
chronic
condition*
Note: FPL refers to federal poverty level. * Respondent reported having at least one of the following chronic conditions: hypertension or
high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease; high cholesterol; or depression or anxiety.
Base: Respondents who were insured all year and reported their income level and out-of-pocket costs.
Source: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.
Adults with low-incomes were the most likely to spend a large share of their income on
uncovered health care costs.4 Two of five (41%) adults with incomes under 100 percent of poverty
($11,490 for an individual and $23,550 for a family of four) who had insurance for the full year
spent 5 percent or more of their income on out-of-pocket medical costs and 31 percent spent 10
percent of their income. In the next-higher income category, 100 percent to 199 percent of poverty
($22,980 for an individual and $47,100 for a family of four), 31 percent of adults spent 5 percent or
more of their income on medical services not covered by their health plans.
People with health problems have higher costs than those who are healthier, and the survey
finds that some of that extra cost is shouldered by patients and their families. Insured adults in fair
or poor health or those who reported at least one chronic condition were more likely to spend large
shares of their income on medical costs not covered by their insurance than insured adults in better
health.5
Thirteen Percent of Privately Insured Adults Have Deductibles Equal to 5 Percent
or More of Income
When people use their health insurance, they incur out-of-pocket costs. A health plan’s deductible
provides an indicator of the financial protection a plan offers and the risk of incurring costs even
before a person uses their plan. Adults in the survey were asked whether their plan had a per-person
deductible and, if so, what the size of the deductible was. We then calculated the deductible as a share
of their income.
Since few people with Medicaid have deductibles, we looked at adults’ experience with
deductibles among those who reported having a private plan at the time of the survey. Among
adults with private insurance, 13 percent had a deductible of 5 percent or more of income (Exhibit
2). Adults with low and moderate incomes were the most likely to have deductibles that were high
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The Commonwealth Fund
Exhibit 2. Privately Insured Adults with Low Incomes Were the Most Likely to Have
Deductibles That Could Potentially Use 5 Percent or More of Their Annual Income
Percent of privately insured adults ages 19–64 whose deductible is 5% or more of income*
50
40
30
20
25
20
18
13
10
0
5
Total
<100%
FPL
100%–199%
FPL
200%–399%
FPL
400%+
FPL
Note: FPL refers to federal poverty level.
* Base: Respondents who reported their income level and deductible for their private insurance plan (includes those who are
currently covered by employer-provided insurance, a marketplace plan, or a plan they purchased through the individual market
outside of the marketplaces).
Source: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.
relative to their income: one-quarter of privately insured adults with incomes under poverty and
about one of five with incomes between 100 percent and 399 percent of poverty had deductibles that
equaled 5 percent or more of income.
Many Adults Say Their Deductibles Are Unaffordable
When we asked privately insured adults with deductibles if they could afford them, more than two
of five (43%) said their deductible was somewhat, very difficult, or impossible to afford (Exhibit
3). People with low and moderate incomes were more likely to report difficulties. Nearly three of
five (58%) adults with incomes under 100 percent of poverty and two-thirds (64%) of those with
incomes between 100 percent and 199 percent of poverty reported it was difficult to afford their
deductibles. About half (49%) of adults with incomes in the next higher income category—200 percent to 399 percent of poverty—reported difficulty affording deductibles, compared with one-quarter
(27%) of those with incomes above 400 percent of poverty.
Adults with High Deductibles Report Delaying Needed Health Care
One rationale for adding deductibles to health plans is that they will create disincentives for consumers to use health care that might be of limited value, thereby lowering costs and limiting premium
growth over time. But the survey finds evidence that deductibles also create disincentives for people
to get needed care.
Privately insured adults with high deductibles relative to their income were significantly more
likely to report delaying or avoiding needed health care than those with lower deductibles. Two of five
(40%) adults with deductibles of 5 percent or more of income reported that because of their deductible, they had not gone to the doctor when sick, did not get a preventive care test, skipped a recommended follow-up test, or did not get needed specialist care (Exhibit 4). Adults who had deductibles
that were smaller relative to income reported avoiding care at lower rates. Still, nearly one-quarter
(23%) of privately insured adults who had deductibles that were less than 5 percent of income said
they did not get needed care because of their deductible.
Too High a Price: Out-of-Pocket Health Care Costs in the U.S.
5
Exhibit 3. About Three of Five Privately Insured Adults with Low Incomes
Reported That It Was Difficult or Impossible to Afford Their Deductible
How easy or difficult is it for you to afford your deductible?
Very difficult or impossible
Total
14
43
<100% FPL*
23
58
100%–199% FPL
27
64
200%–399% FPL
Somewhat easy
Somewhat difficult
49
15
400%+ FPL
29
35
35
26
14
37
28
7 36
33
27 6
20
34
21
Very easy
54
40
15
40
49
31
71
Percent
Privately insured adults ages 19–64 who have a deductible
Notes: FPL refers to federal poverty level. Bars may not sum to 100% because of “don’t know” responses or refusal to respond;
segments may not sum to subtotals because of rounding.
* Sample size n=94.
Source: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.
Exhibit 4. Two of Five Privately Insured Adults with Deductibles That Comprise 5 Percent
or More of Their Income Reported Delaying or Avoiding Needed Health Care Because of
Their Deductible
Percent responding “yes”
75
Deductible <5% of income
Deductible 5% or more of income
50
40
27
25
0
29
23
13
10
Had a medical
problem, but did
not go to a doctor
or clinic
Did not get
preventive
care test
14
22
23
13
Skipped a medical Did not see a
test, treatment, specialist when
or follow-up you or your doctor
recommended
thought you
by a doctor needed to see one
At least one
cost-related
access
problem
Privately insured adults ages 19–64 who have a deductible
Base: Respondents who reported their income level and deductible for their private insurance plan (includes those who are
currently covered by employer-provided insurance, a marketplace plan, or a plan they purchased through the individual market
outside of the marketplaces).
Source: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.
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The Commonwealth Fund
WHY THE AFFORDABLE CARE ACT IS EXPECTED TO REDUCE THE NUMBER OF
UNDERINSURED AMERICANS
The Affordable Care Act aims to improve the quality of health insurance sold in the individual
and small-group markets and expand eligibility for Medicaid, which includes little or no cost-sharing.
The law improves the comprehensiveness of coverage by requiring that health plans sold in
the individual and small-group markets cover an essential health benefits package, which may
vary only by the degree of cost-sharing consumers bear—for example, the size of deductibles,
copayments, and coinsurance. To further protect consumers and help them understand the
costs they might be responsible for, the law requires insurance plans to be sold at four distinct
levels in those markets: bronze, silver, gold, and platinum. Bronze plans cover an average of
60 percent of the medical costs incurred by enrollees in a plan; silver plans cover 70 percent;
gold plans cover 80 percent; and platinum plans cover 90 percent. This is also known as the
actuarial value of a plan. The law also provides cost-sharing subsidies for people with incomes
under 250 percent of poverty ($28,725 for an individual and $58,875 for a family of four) who
enroll in silver plans through the marketplaces.
Prior to the Affordable Care Act, as many as half of plans sold in many state individual
insurance markets had actuarial values of less than 60 percent.6 In addition, health insurers
in most states excluded conditions they expected would be costly, such as maternity care, or
limited what health plans would pay in a year and over a lifetime. The law has banned all of
these practices.
Employer plans have traditionally been far more comprehensive than individual market plans.7
But the law includes provisions aimed at protecting people with employer coverage. Workers
with incomes under 400 percent of poverty are eligible for tax credits for plans purchased in
the marketplaces if they are offered a plan by their employer that has an actuarial value of less
than 60 percent, and large employers that do this will pay a penalty. In addition, employers are
now required to provide all federally recommended preventive care services without cost-sharing.
Lower-Income Adults Report Difficulty Affording Copayments, Delaying Needed Care
In addition to deductible size, another indicator of the financial protection a health plan offers is the
amount of copayments or coinsurance a health plan requires when people go to the doctor or fill a prescription. The survey asked people whether their health plan included copayments or coinsurance and,
if so, how easy or difficult it was for them to afford these potential costs. In this analysis, we include all
insured adults because people with Medicaid and other public insurance plans also may have copayments.
Three-quarters (76%) of insured adults who have copayments or coinsurance said it was very or
somewhat easy to afford them (Exhibit 5). Adults with lower incomes were significantly more likely
to say it was difficult to afford their copayments or coinsurance than were adults with higher incomes.
Difficulty in affording copayments appears to affect people’s health care decisions. People with
low incomes who had copayments or coinsurance were more likely to say they had delayed or avoided
needed care because of these costs than were those with higher incomes. Nearly half (46%) of insured
adults with incomes under 200 percent of poverty said that because of their copayments or coinsurance, they had either not filled a prescription, not gone to the doctor when they were sick, skipped a
medical test or follow-up visit recommended by a doctor, or not seen a specialist when they or their
doctor thought they needed one (Exhibit 6). Overall, lower-income adults delayed or avoided care
because of their copayments at twice the rate of adults with higher incomes. However, adults with
relatively higher incomes also reported issues: one of five (21%) adults with incomes of 200 percent
of poverty or more reported not filling a prescription or delaying care because of copayments.
Too High a Price: Out-of-Pocket Health Care Costs in the U.S.
7
Exhibit 5. Most Insured Adults with Plans That Require a Copayment or Coinsurance
Said It Was Somewhat or Very Easy to Afford Them
In the past 12 months, how easy or difficult was it for you to afford your copayments or
coinsurance when you visited a doctor or clinic, or when you filled a prescription?
Very difficult or impossible
23
Total
35
16
7
<100% FPL
40
16
24
100%–199% FPL
38
12
26
20 4
200%–399% FPL
Somewhat easy
Somewhat difficult
76
29
37
58
23
42
60
36
32
10 2 8
400%+ FPL
41
29
16
Very easy
78
57
90
Percent
Insured adults ages 19–64 who pay a copayment or coinsurance
Notes: FPL refers to federal poverty level. Bars may not sum to 100% because of “don’t know” responses or refusal to respond;
segments may not sum to subtotals because of rounding.
Source: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.
Exhibit 6. Insured Adults with Lower Incomes Were More Likely to Report They Had
Delayed or Avoided Getting Care Because of Their Copayments or Coinsurance
Percent responding “yes”
75
<200% FPL
200% FPL or more
46
50
30
28
28
24
25
10
0
10
Had a medical
problem, but did
not go to a doctor
or clinic
Did not
fill a
prescription
12
21
10
Skipped a medical Did not see a
test, treatment, specialist when
or follow-up you or your doctor
recommended
thought you
by a doctor needed to see one
At least one
cost-related
access
problem
Insured adults ages 19–64 who pay a copayment or coinsurance
Note: FPL refers to federal poverty level.
Source: The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014.
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The Commonwealth Fund
CONCLUSION AND POLICY IMPLICATIONS
Changes in health benefit design over the past decade across all forms of insurance have emphasized greater consumer cost-sharing through higher deductibles, copayments, and coinsurance.
Recently, some policymakers have suggested that insurers should be allowed to sell health plans in
the Affordable Care Act’s marketplaces that require even greater cost-sharing than the least protective
bronze-level plans.8
The results of this survey show that these trends toward greater cost-sharing, combined with
little or no growth in median family income, have left many working Americans in the middle and
lower end of the income distribution with large health care cost burdens. About three of five adults
with low incomes and half of those with moderate incomes say that their deductibles are difficult or
impossible to afford.
Cost-sharing in health plans is affecting people’s medical decisions in ways that should be
of concern to policymakers and the medical community. Two of five adults who had deductibles
that were high relative to their income said they had delayed or avoided needed care because of the
deductible. Nearly one-quarter of people with high deductibles cited them as the reason they had not
gotten a preventive care test, even though by law these tests are excluded from deductibles.
The Affordable Care Act has the potential to reduce the number of Americans who are
underinsured though reforms aimed at improving the comprehensiveness of coverage in the individual and small-group markets. But the underlying rate of growth in health care costs relative to
income growth also will have an impact on the number of underinsured people in the coming years.
More than 400 pages of the Affordable Care Act are devoted to new programs and payment methods
aimed at improving the quality of health care and lowering costs. While these provisions are directed
at Medicare, it is expected they will stimulate change throughout the delivery system, and there is
evidence this is occurring. A systemwide effort to reduce health care cost growth will be needed to
ensure the affordability of both insurance and health care for working Americans over time. Future
waves of this survey, along with other Commonwealth Fund surveys, will help gauge the nation’s
progress on these efforts through the eyes of consumers in the years to come.
Too High a Price: Out-of-Pocket Health Care Costs in the U.S.
9
Notes
1
G. Claxton, M. Rae, N. Panchal et al., “Health Benefits in 2014: Stability in Premiums and Coverage for
Employer-Sponsored Plans,” Health Affairs, Oct. 1, 2014 33(10):1851–60; and C. Schoen, J. Lippa, S.
Collins, and D. Radley, State Trends in Premiums and Deductibles, 2003–2011: Eroding Protection and Rising
Costs Underscore Need for Action (New York: The Commonwealth Fund, Dec. 2012).
2
Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits: 2014 Annual
Survey (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, Sept. 10, 2014), http://ehbs.kff.org/.
3
C. Schoen, M. M. Doty, R. H. Robertson, and S. R. Collins, “Affordable Care Act Reforms Could Reduce
the Number of Underinsured U.S. Adults by 70 Percent,” Health Affairs, Sept. 2011 30(9):1762–71; C.
Schoen, S. R. Collins, J. L. Nicholson, and M. M. Doty, “How Many Are Underinsured? Trends Among
U.S. Adults, 2003 and 2007,” Health Affairs Web Exclusive, June 10, 2008, w298–w309; C. Schoen,
M. M. Doty, S. R. Collins, and A. L. Holmgren, “Insured But Not Protected: How Many Adults Are
Underinsured?” Health Affairs Web Exclusive, June 14, 2005, w5-289–w5-302; and S. R. Collins, R. H.
Robertson, T. Garber, and M. M. Doty, Insuring the Future: Current Trends in Health Coverage and the Effects
of Implementing the Affordable Care Act (New York: The Commonwealth Fund, April 2013).
4
All reported differences are statistically significant at the p<= 0.05 level or better unless otherwise noted.
5
Chronic conditions included hypertension or high blood pressure; heart disease; diabetes; asthma, emphysema or lung disease; high cholesterol; or depression or anxiety.
6
J. R. Gabel, R. Lore, R. D. McDevitt et al., “More Than Half of Individual Health Plans Offer Coverage That
Falls Short of What Can Be Sold Through Exchanges as of 2014,” Health Affairs Web First, May 23, 2012.
7
Ibid.
8
Senator Mark Begich (D-Alaska) and six cosponsors, S.1729, “A bill to amend the Patient Protection and
Affordable Care Act to provide further options with respect to levels of coverage under qualified health
plans,” introduced on November 11, 2013, https://www.congress.gov/bill/113th-congress/senate-bill/1729/
all-info; and America’s Health Insurance Plans, Continuing Our Commitment to Consumers: Solutions That
Will Enhance Affordability, Stability and Accessibility in the New Health Care Marketplace (Washington, D.C.:
AHIP, June 2014), http://www.ahip.org/News/Press-Room/2014/Policy-Solutions/.
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The Commonwealth Fund
SURVEY METHODOLOGY
The Commonwealth Fund Health Care Affordability Tracking Survey, September–October 2014,
was conducted by SSRS from September 10 to October 5, 2014, as a part of SSRS’ weekly nationally representative omnibus survey. The survey consisted of a 15-minute telephone interviews
in English or Spanish and was conducted among a random, nationally representative sample of
2,751 adults ages 19 to 64 living in the continental United States. Overall 1,127 interviews were
conducted with respondents on landline telephones and 1,624 interviews were conducted on cellular phones, including 1,012 with respondents who live in households with no landline telephone
access.
The data are weighted to adjust for the fact that not all survey respondents were selected with
the same probabilities, the overlapping landline and cellular phone samples, and disproportionate nonresponse that might bias results. Data are weighted to the U.S. 19-to-64 adult population
by age, race, gender, region, marital status, education, and population density, based on the U.S.
Census Bureau’s 2014 March Supplement to the Current Population Survey (CPS) and household
telephone use using the CDC’s National Health Interview Survey. The resulting weighted sample is
representative of the approximately 190.7 million U.S. adults ages 19 to 64.
The survey has an overall margin of sampling error of +/–2.1 percentage points at the 95 percent
confidence level. The landline portion of the survey achieved a 9.9 percent response rate and
the cellular phone sample achieved a 5.7 percent response rate. The overall response rate was
7.3 percent.
Too High a Price: Out-of-Pocket Health Care Costs in the U.S.
11
About the Authors
Sara R. Collins, Ph.D., is vice president for Health Care Coverage and Access at The
Commonwealth Fund. An economist, Dr. Collins joined the Fund in 2002 and has led the Fund’s
national program on health insurance since 2005. Since joining the Fund, she has led several
national surveys on health insurance and authored numerous reports, issue briefs, and journal
articles on health insurance coverage and policy. She has provided invited testimony before several
Congressional committees and subcommittees. Prior to joining the Fund, Dr. Collins was associate director/senior research associate at the New York Academy of Medicine. Earlier in her career,
she was an associate editor at U.S. News & World Report, a senior economist at Health Economics
Research, and a senior health policy analyst in the New York City Office of the Public Advocate.
Dr. Collins holds a Ph.D. in economics from George Washington University.
Petra W. Rasmussen, M.P.H., is senior research associate for the Fund’s Health Care Coverage
and Access program. In this role, Ms. Rasmussen is responsible for contributing to survey questionnaire development, analyzing survey results through statistical analysis, and writing survey
issue briefs and articles. In addition, she is involved in tracking and researching emerging policy
issues regarding health reform and the comprehensiveness and affordability of health insurance
coverage and access to care in the United States. Ms. Rasmussen holds an M.P.H. in health policy
and management from Columbia University’s Mailman School of Public Health.
Michelle McEvoy Doty, Ph.D., is vice president of survey research and evaluation for The
Commonwealth Fund. She has authored numerous publications on cross-national comparisons
of health system performance, access to quality health care among vulnerable populations, and
the extent to which lack of health insurance contributes to inequities in quality of care. Dr. Doty
holds an M.P.H. and a Ph.D. in public health from the University of California, Los Angeles.
Sophie Beutel is program assistant in the Health Care Coverage and Access Program. In this role,
she is responsible for providing daily support for the program with responsibilities ranging from
daily administrative and grants management tasks to writing and research responsibilities, including tracking developments in the implementation of the Affordable Care Act. Prior to joining the
Fund, she was a summer intern with the State of Rhode Island Department of Health. Ms. Beutel
graduated from Brown University with a B.A. in Science and Society, on the Health and Medicine
track.
Acknowledgments
The authors gratefully acknowledge the contributions of Robyn Rapoport and Erin Czyzewicz of
SSRS; and David Blumenthal, Barry Scholl, Chris Hollander, Deborah Lorber, Paul Frame, and
Rose Kleiman of The Commonwealth Fund.
Editorial support was provided by Deborah Lorber.
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COMMONWEALTH
FUND
www.commonwealthfund.org